There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The ‘Emerging mental health systems in low- and middle-income countries (LMICs)’ (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.

To provide a set of proposed recommendations for mental health system strengthening in LMICs.

The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012–2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.

The proposed recommendations align closely with the World Health Organization's key health system strengthening ‘building blocks’ of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.

These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.

None.

The coronavirus (COVID-19) pandemic causes healthcare professionals to suffer mental health problems such as psychological distress, anxiety, depression, denial and fear. However, studies are lacking related to Ethiopia and to Africa in general.

To study the mental health of healthcare professionals during the COVID-19 pandemic in Ethiopia.

A hospital-based cross-sectional study was conducted at Jimma University Medical Center among 249 healthcare professionals. The data were collected using self-administered questionnaires between 22 and 28 March 2020. The psychological impact was assessed using the Impact of Event Scale – Revised (IES-R) and symptoms of insomnia were measured using the Insomnia Severity Index (ISI). Social support was evaluated using the three-item Oslo Social Support Scale. Data were analysed using logistic regression to examine mutually adjusted associations, expressed as adjusted odds ratios. The psychosocial status of the healthcare professionals was predicted using a classification tree model supported by the genetic search method.

The prevalence of psychological distress among healthcare professionals was 78.3%. The mean IES-R score was 34.2 (s.d. = 19.4). The ISI score indicated that the prevalence of insomnia was 50.2%. Higher psychological distress was associated with younger age, having insomnia, not having a daily update on COVID-19, and feeling stigmatised and rejected in the neighbourhood because of hospital work.

This study indicates that, in Ethiopia, the prevalence of psychological distress among healthcare professionals is high and associated with specific sociodemographic risks.

The COVID-19 pandemic and associated restrictions are expected to affect the mental health of the population, especially people with intellectual disability and/or autism spectrum disorder, because of a variety of biological and psychosocial reasons.

This study aimed to estimate if COVID-19 restrictions are associated with a change in number of total consultations carried out by psychiatrists and prescription of psychotropic medication in people with intellectual disability and/or autism spectrum disorder, within a community intellectual disability service.

A quantitative observational study was conducted, involving retrospective and prospective data collection before and during lockdown. Data was collected on a spreadsheet and emailed to all psychiatrists working within the Coventry and Warwickshire Partnership NHS Trust-wide community intellectual disability service. Variables included total consultations, medication interventions, types of medications used, multidisciplinary team input and clinical reasons for medication interventions. Data was analysed separately for child and adolescent mental health services (CAMHS) and adult intellectual disability teams, and for the whole service.

During the lockdown period, total consultations in the community intellectual disability service increased by 19 per week and medication interventions increased by two per week. Multidisciplinary team input increased in CAMHS from 0.17 to 0.71 per week and in adult intellectual disability from 5.7 to 6.5 per week. Hypnotics and benzodiazepines were the most commonly prescribed psychotropic medications during the lockdown period.

COVID-19-related lockdown resulted in an increase in medication interventions, total consultations and involvement of multidisciplinary teams to manage mental health and behavioural issues in people with intellectual disability and/or autism spectrum disorder.

Many psychiatrists are worried their patients, at increased risk for COVID-19 complications, are precluded from receiving appropriate testing. There is a lack of epidemiological data on the associations between psychiatric disorders and COVID-19 testing rates and testing outcomes.

To compare COVID-19 testing probability and results among individuals with psychiatric disorders with those without such diagnoses, and to examine the associations between testing probability and results and psychiatric diagnoses.

This is a population-based study to perform association analyses of psychiatric disorder diagnoses with COVID-19 testing probability and such test results, by using two-sided Fisher exact tests and logistic regression. The population were UK Biobank participants who had undergone COVID-19 testing. The main outcomes were COVID-19 testing probability and COVID-19 test results.

Individuals with psychiatric disorders were overrepresented among the 1474 UK Biobank participants with test data: 23% of the COVID-19 test sample had a psychiatric diagnosis compared with 10% in the full cohort (P < 0.0001). This overrepresentation persisted for each of the specific psychiatric disorders tested. Furthermore, individuals with a psychiatric disorder (P = 0.01), particularly substance use disorder (P < 0.005), had negative test results significantly more often than individuals without psychiatric disorders. Sensitivity analyses confirmed our results.

In contrast with our hypotheses, UK Biobank participants with psychiatric disorders have been tested for COVID-19 more frequently than individuals without a psychiatric history. Among those tested, test outcomes were more frequently negative for registry participants with psychiatric disorders than in others, countering arguments that people with psychiatric disorders are particularly prone to contract the virus.

Epilepsy and mental illness share similar problems in terms of stigma, as a result of centuries of superstition, ignorance and misbeliefs. Stigma leads not only to discrimination and civil and human rights violations but also to poor access to healthcare and non-adherence or decreased adherence to treatment, ultimately increasing morbidity and mortality. Despite continuous efforts in fighting stigma in these conditions, there is very limited knowledge on the phenomenon of double stigma, meaning the impact of having two stigmatised conditions at the same time.

To discuss double stigma in mental health with special reference to epilepsy.

Articles were identified through searches in PubMed up to 31 October 2019 using the search terms ‘epilepsy’, ‘psychiatric disorders’, ‘stigma’ and additional material was identified from the authors’ own files and from chosen bibliographies.

Double stigma is gaining attention for other stigmatised medical conditions, such as HIV, however, the literature on epilepsy is almost non-existent and this is quite astonishing given that one in three people with epilepsy have a lifetime diagnosis of a psychiatric condition. Felt (perceived) stigma and psychiatric disorders, particularly depression, create a vicious circle in epilepsy maintaining both, as depression correlates with stigma and vice versa as well as epilepsy and depression serving as bidirectional risk factors. This phenomenon has no geographical and economic boundaries as similar data have been reported for low-income and high-income countries.

Governments and policymakers as well as health services, patients’ organisations, families and the general public need to be aware of the phenomenon of double stigma in order to develop campaigns and interventions tailored for these patients.

The term ‘global mental health’ came to the fore in 2007, when the Lancet published a series by that name.

To review all peer-reviewed articles using the term ‘global mental health’ and determine the implicit priorities of scientific literature that self-identifies with this term.

We conducted a systematic review to quantify all peer-reviewed articles using the English term ‘global mental health’ in their text published between 1 January 2007 and 31 December 2016, including by geographic regions and by mental health conditions.

A total of 467 articles met criteria. Use of the term ‘global mental health’ increased from 12 articles in 2007 to 114 articles in 2016. For the 111 empirical studies (23.8% of articles), the majority (78.4%) took place in low- and middle-income countries (LMICs), with the most in Sub-Saharan Africa (28.4%) and South Asia (25.5%) and none from Central Asia. The most commonly studied mental health conditions were depression (29.7%), psychoses (12.6%) and conditions specifically related to stress (12.6%), with fewer studies on epilepsy (2.7%), self-harm and suicide (1.8%) and dementia (0.9%). The majority of studies lacked contextual information, including specific region(s) within countries where studies took place (20.7% missing), specific language(s) in which studies were conducted (36.9% missing), and details on ethnic identities such as ethnicity, caste and/or tribe (79.6% missing) and on socioeconomic status (85.4% missing).

Research identifying itself as ‘global mental health’ has focused predominantly on depression in LMICs and lacked contextual and sociodemographic data that limit interpretation and application of findings.

None.

Violence among released prisoners with psychosis is an important public health problem. It is unclear whether treatment in prison can influence criminal behaviour subsequent to release.

To investigate whether treatment in prison can delay time to reoffending.

Our sample consisted of 1717 adult prisoners in England and Wales convicted of a serious violent or sexual offence. We used Cox regression to investigate the effects of treatment received in prison on associations between mental illness and time to first reconviction following release.

Prisoners with current symptoms of schizophrenia reoffended quicker following release. Nevertheless, treatment with medication significantly delayed time to violence (18% reduction). Treatment for substance dependence delayed violent and non-violent reoffending among prisoners with drug-induced psychosis.

Identifying prisoners with psychosis and administering treatment in prison have important protective effects against reoffending. Repeated screening with improved accuracy in identification is necessary to prevent cases being missed.

Suicide prediction models have been formulated in a variety of ways and are heterogeneous in the strength of their predictions. Machine learning has been a proposed as a way of improving suicide predictions by incorporating more suicide risk factors.

To determine whether machine learning and the number of suicide risk factors included in suicide prediction models are associated with the strength of the resulting predictions.

Random-effect meta-analysis of exploratory suicide prediction models constructed by combining two or more suicide risk factors or using clinical judgement (Prospero Registration CRD42017059665). Studies were located by searching for papers indexed in PubMed before 15 August 2020 with the term suicid* in the title.

In total, 86 papers reported 102 suicide prediction models and included 20 210 411 people and 106 902 suicides. The pooled odds ratio was 7.7 (95% CI 6.7–8.8) with high between-study heterogeneity (I2 = 99.5). Machine learning was associated with a non-significantly higher odds ratio of 11.6 (95% CI 6.0–22.3) and clinical judgement with a non-significantly lower odds ratio of 4.7 (95% CI 2.1–10.9). Models including a larger number of suicide risk factors had a higher odds ratio when machine-learning studies were included (P = 0.02). Among non-machine-learning studies, suicide prediction models including fewer risk factors performed just as well as those including more risk factors.

Machine learning might have the potential to improve the performance of suicide prediction models by increasing the number of included suicide risk factors but its superiority over other methods is unproven.

Migration has been reported to be associated with higher prevalence of mental disorders and suicidal behaviour.

To examine the prevalence of emotional and behavioural difficulties, suicidal ideation and suicide attempts among migrant adolescents and their non-migrant peers.

A school-based survey was completed by 11 057 European adolescents as part of the Saving and Empowering Young Lives in Europe (SEYLE) study.

A previous suicide attempt was reported by 386 (3.6%) adolescents. Compared with non-migrants, first-generation migrants had an elevated prevalence of suicide attempts (odds ratio (OR) 2.08; 95% CI 1.32–3.26; P=0.001 for European migrants and OR 1.86; 95% CI 1.06–3.27; P=0.031 for non-European migrants) and significantly higher levels of peer difficulties. Highest levels of conduct and hyperactivity problems were found among migrants of non-European origin.

Appropriate mental health services and school-based supports are required to meet the complex needs of migrant adolescents.

In recent years, concerns have been raised that too many patients stay for too long in forensic psychiatric services and that this is a particular problem in those with an intellectual disability.

To compare the characteristics, needs, and care pathways of long-stay patients with and without intellectual disability within forensic psychiatric hospital settings in England.

File reviews and questionnaires were completed for all long-stay patients in high secure and a representative sample of those in medium secure settings in England. Between-group analyses comparing patients with and without intellectual disability are reported.

Of the 401 long-stay patients, the intellectual disability and non-intellectual disability groups were strikingly similar on many sociodemographic, clinical and forensic variables. The intellectual disability group had significantly lower lengths of stay, fewer criminal sections, restriction orders and prison transfers, and higher levels of behavioural incidents and risk assessment scores.

In spite of similar offence histories and higher risk levels, those with intellectual disability appear to be diverted away from the criminal justice system and have shorter lengths of stay. This has implications about the applicability of the Transforming Care programme to this group.

There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals.

This study identified and developed the domains that should be used to measure treatment outcomes for this population.

A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts.

The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction.

To index recovery, services need to measure treatment outcomes using this framework.

The psychiatric health burden of prisoners is substantial. However, there is a lack of high-quality studies of psychiatric disorders among young adults with a high risk of reoffending.

To investigate the lifetime prevalence of psychiatric disorders and use of mental health services among young male violent offenders and the impact of childhood-onset conduct disorder (COCD).

A nationally representative cohort (n = 270, age 18–25) of male offenders was followed back in medical records and clinically assessed by gold standard methods. Lifetime prevalences are presented together with odds ratios (ORs) as risk estimates in relation to COCD.

Previous use of psychiatric services among the participants was high but their lifetime psychiatric morbidity was even higher, with 93% meeting criteria for at least one Axis I disorder. The COCD group was overrepresented in most clinical categories and carried five times higher odds (OR = 5.1, 95% CI 2.0–12.8) of a psychotic disorder, three times higher odds (OR = 3.2, 95% CI 1.2–8.5) of a substance use disorder and two times higher odds of a mood disorder (OR = 2.3, 95% CI 1.3–4.0) or anxiety disorder (OR = 2.0, 95% CI 1.1–3.5).

The mental health burden is substantial among young violent offenders, and COCD is an important indicator of future mental health problems which must be a priority for public health efforts.

Recently, artificial intelligence-powered devices have been put forward as potentially powerful tools for the improvement of mental healthcare. An important question is how these devices impact the physician-patient interaction.

Aifred is an artificial intelligence-powered clinical decision support system (CDSS) for the treatment of major depression. Here, we explore the use of a simulation centre environment in evaluating the usability of Aifred, particularly its impact on the physician–patient interaction.

Twenty psychiatry and family medicine attending staff and residents were recruited to complete a 2.5-h study at a clinical interaction simulation centre with standardised patients. Each physician had the option of using the CDSS to inform their treatment choice in three 10-min clinical scenarios with standardised patients portraying mild, moderate and severe episodes of major depression. Feasibility and acceptability data were collected through self-report questionnaires, scenario observations, interviews and standardised patient feedback.

All 20 participants completed the study. Initial results indicate that the tool was acceptable to clinicians and feasible for use during clinical encounters. Clinicians indicated a willingness to use the tool in real clinical practice, a significant degree of trust in the system's predictions to assist with treatment selection, and reported that the tool helped increase patient understanding of and trust in treatment. The simulation environment allowed for the evaluation of the tool's impact on the physician–patient interaction.

The simulation centre allowed for direct observations of clinician use and impact of the tool on the clinician–patient interaction before clinical studies. It may therefore offer a useful and important environment in the early testing of new technological tools. The present results will inform further tool development and clinician training materials.

Being a current psychiatric in-patient is one of the strongest statistical risk factors for suicide. It is usually assumed that this strong association is not causal but is a result of the combination of the selection of high-risk patients for admission and the imperfect protection from suicide afforded by psychiatric wards. Logically, a third factor, which is causal, might play a role in the association. It has recently been suggested that adverse experiences in psychiatric units such as trauma, stigma and loss of social role might precipitate some in-patient suicides.

To consider whether there is a causal association between psychiatric hospitalisation and suicide.

We used the framework of Austin Bradford Hill's criteria for assessing causality in epidemiology to consider the possibility that psychiatric hospitalisation might causally contribute to the extent and variation in in-patient suicide rates.

The association between psychiatric hospitalisation and suicide clearly meets five of the nine Hill's criteria (strength of association, consistency, plausibility, coherence and analogy) and partially meets three of the remaining four criteria (gradient of exposure, temporality and experimental evidence).

Admission to hospital itself might play a causal role in a proportion of in-patient suicides. The safety of being in hospital with respect to suicide could be examined with a large-scale randomised controlled trial (RCT). In the absence of an RCT, the possibility of a causal role provides further impetus to calls to make care in the community more available and psychiatric hospitals more acceptable to patients.

Treatment for hoarding disorder is typically performed by mental health professionals, potentially limiting access to care in underserved areas.

We aimed to conduct a non-inferiority trial of group peer-facilitated therapy (G-PFT) and group psychologist-led cognitive–behavioural therapy (G-CBT).

We randomised 323 adults with hording disorder 15 weeks of G-PFT or 16 weeks of G-CBT and assessed at baseline, post-treatment and longitudinally (≥3 months post-treatment: mean 14.4 months, range 3–25). Predictors of treatment response were examined.

G-PFT (effect size 1.20) was as effective as G-CBT (effect size 1.21; between-group difference 1.82 points, t = −1.71, d.f. = 245, P = 0.04). More homework completion and ongoing help from family and friends resulted in lower severity scores at longitudinal follow-up (t = 2.79, d.f. = 175, P = 0.006; t = 2.89, d.f. = 175, P = 0.004).

Peer-led groups were as effective as psychologist-led groups, providing a novel treatment avenue for individuals without access to mental health professionals.

C.A.M. has received grant funding from the National Institutes of Health (NIH) and travel reimbursement and speakers’ honoraria from the Tourette Association of America (TAA), as well as honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. K.D. receives research support from the NIH and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. R.S.M. receives research support from the National Institute of Mental Health, National Institute of Aging, the Hillblom Foundation, Janssen Pharmaceuticals (research grant) and the Alzheimer's Association. R.S.M. has also received travel support from the National Institute of Mental Health for Workshop participation. J.Y.T. receives research support from the NIH, Patient-Centered Outcomes Research Institute and the California Tobacco Related Research Program, and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. All other authors report no conflicts of interest.

Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising.

To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys.

We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10–19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests.

Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17–19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35–0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28–0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19–2.94, P = 0.007).

There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

It is well established that migration and ethnic minority status are risk factors for psychotic disorders. Recent studies have aimed to determine if they are also associated with subclinical psychosis (psychotic-like experiences and schizotypal traits).

We aimed to determine to what extent migrant and ethnic minority groups are associated with higher risk of subclinical psychosis.

We conducted a systematic review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and examined findings by ethnicity, migrant status, outcomes of subclinical psychosis and host country. A meta-analysis was carried out with robust variance estimation where possible, to handle statistically dependent effect size estimates.

We included 28 studies (19 studies on psychotic-like experiences and 9 studies on schizotypal traits) and found that ethnicity, but not migrant status, was associated with current and lifetime psychotic-like experiences. In the narrative analysis, we observed the effect of psychosocial risk factors on this association: Black ethnicity groups showed consistent increased prevalence of current and lifetime psychotic-like experiences compared with the reference population across countries.

More generalisable and standardised cohort studies of psychotic-like experiences and schizotypal traits in relation to migration/ethnicity are necessary to examine the effects of exposures and outcomes in different contexts, and to understand the underlying mechanisms of the association between subclinical psychosis and migrant and ethnic minority status.

None.

The UK Biobank contains data with varying degrees of reliability and completeness for assessing depression. A third of participants completed a Mental Health Questionnaire (MHQ) containing the gold-standard Composite International Diagnostic Interview (CIDI) criteria for assessing mental health disorders.

To investigate whether multiple observations of depression from sources other than the MHQ can enhance the validity of major depressive disorder (MDD).

In participants who did not complete the MHQ, we calculated the number of other depression measures endorsed, for example from hospital episode statistics and interview data. We compared cases defined this way with CIDI-defined cases for several estimates: the variance explained by polygenic risk scores (PRS), area under the curve attributable to PRS, single nucleotide polymorphisms (SNPs)-based heritability and genetic correlations with summary statistics from the Psychiatric Genomics Consortium MDD genome-wide association study.

The strength of the genetic contribution increased with the number of measures endorsed. For example, SNP-based heritability increased from 7% in participants who endorsed only one measure of depression, to 21% in those who endorsed four or five measures of depression. The strength of the genetic contribution to cases defined by at least two measures approximated that for CIDI-defined cases. Most genetic correlations between UK Biobank and the Psychiatric Genomics Consortium MDD study exceeded 0.7, but there was variability between pairwise comparisons.

Multiple measures of depression can serve as a reliable approximation for case status where the CIDI measure is not available, indicating sample size can be optimised using the entire suite of UK Biobank data.